Empowering Health Personnel

Mohini BhavsarSenior Field ManagerDimagi Inc. mbhavsar@dimagi.com

GFMER 2013Empowering Health Personnel#

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#Community Health Worker Challenges#2Community Health SystemsCommunity Health Workers (CHW)

Positive health outcomesBetter CHW performance

Better health outcomes#34

#Roadmap for Rest of TalkDimagi and CommCare

1Stories from India

2Evidence

3Partnerships

4#Dimagi and CommCare

#6Dimagis ExperienceUnique focusOpen Source ProductsEnterprise-class cloud hosting with economies of scale Turnkey configurable solutions that do not require software developers to deploy

Social enterprise founded in 2002 at Harvard and MIT Media Lab, About 40 staff worldwideOffices in Boston, USA; New Delhi, India; and Cape Town, SACore Funding: Bill and Melinda Gates Foundation, IDRC, UN Foundation, Norwegian Government, Rockefeller Foundation, USAID, Vodaphone Foundation, Wellcome Trust#7LogisticsCommunicationData and WorkflowDimagi ProductsData collection and case management solutionJava feature phones or Android smartphones & tabletsSecure and scalable 2-way SMS-based applicationsAny SMS-enabled mobile device.SMS point of service logistics management systemsManage inventory and logistics for remote sites.

Implementation Services: technology enablement, design, and support

CommTrackCommConnectCommCare

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Case Management: Improving Service Delivery

Login Find Client CaseView Client Summary

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Fill Out a Form: Checklist for Pregnancy Danger Signs

##Addressing CHW Challenges

#11Also available on Android Platform

#CommCare: Mobile Solution for Frontline Workers

Manage Apps and UsersRemotely manage your CommCare application and mobile workforce from our web-based application.Monitor & Support WorkforceActive Data Management utilizes the data you collect to focus on the continuous performance improvement of your workforce.Web

Manage DataUse CommCare Mobile for complex data collection, submitted to the web in real-timeManage ClientsUse case management to track client dataEngage with MultimediaUse images, audio, and video to educate and engage frontline workers and their clients.Mobile#13

Worker Monitoring Reports

#Continuous Performance ImprovementSupport for Project Coordinators in managing workforceAnalyze all data submitted to server to improve worker performanceTargeted, actionable follow-up activities for supervisorsWeekly and monthly email reports

Implemented in 25 countries worldwide..#And were seeing tremendous uptake. 50+ active deployments in 25 countries around the world.15

12 April 2012~1000 CHWs14 states15 projects

#In India, for example, we have 1000 CHWs, 14 states, and 15 projects using CommCare. And growing (rapidly). Recently received generous support from USAID to provide free phones and field support to 40 organizations in India in order to get started with using mobile technology. Majority of proposals were MCH, others sex workers, agriculture, education, adolescent counseling, tracking loan defaulters for MFIs.

What weve learned

#17Content specification for technology requires a systematic assessment of your current protocolsBe more specific Uncovers vague and unclear processesBe creative

1#Paper Mobile ApplicationData collection/Surveys: Display conditions Validation constraints Open-ended questions vs. choices

Workflows: Is there redundancy? Organize content to reflect CHWs visit schedule

Media Integration Craft the counseling messages with care Audio messages will be standardized for all beneficiaries

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What do you want your application to do?

Data collection?Counseling?Training reinforcement?Workflow support?#20

Maternal HealthCRS, World Vision, Save the ChildrenUttar Pradesh, Maharashtra, RajasthanGuided Counseling and Care Tracking#21

Sexual Reproductive HealthPathfinder InternationalBiharNon-Guided Counseling (Chapters & Lessons)#Recommended Counseling (Mixed Method)#

Malnutrition, RMFMadhya PradeshWorkflow Support/Protocol Guidance#

Worksheet Part One - ContentAdd husband name or other details? What happens if duplicate names?Add constraints for age. < or > a particular age?Any constraints on date? Cannot enter future date or passed a certain date (10 months from now?)What happens if woman is not sure if she received a tetanus shot? Should there be a third option? How many days after the last menstrual date should we calculate the third trimester?For child, would you like this message to disappear after 6 months of age?#25Worksheet Part Two - Case Management

#26The CommCare Definition#question codequestion textquestion typeoptions for multiple choice question OR constrainsts for open-ended questionsdisplay conditionaudio description-Englishaudio description-Hindiimage description1client_nameNameopen-ended2client_genderGendermultiple choicemale, female3client_ageAgeinteger10-1004phone_numberPhone numberphone number10 digits5is_pregnantIs the client pregnant?multiple choiceyes, noclient_gender=female6lmpWhen was her last menstrual period?dateyes, nois_pregnant=yes7show_eddEDD: [lmp+274 days]promptis_pregnant=yes8previous_birthHave you given birth in the last 2 years?multiple choiceyes,nois_pregnant=yes9last_birthHow many months ago?integernumber must be between 1 and 24previous_birth=yesDimagis Open Source Image Libraryhttp://www.flickr.com/photos/86561884@N02/sets/

#27The best solutions come from the users themselves. Field testing with CHWs is essential.Global HQIn-country HQField ManagersTalking to CHWsWorking with CHWs

IDEAL INTERVENTIONACTUAL INTERVENTION

2#1Rapid prototyping of a Pregnancy App

V1 - ScoringV2 - Checklist & CounselingV3 SeparateCounselingV4 - Edit formV5 Infant sub-cases

April 2011May 2011May 2012June 2012July 2012

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Icons and audio playback in the menus

V6 Menus for low literate/illiterate usersMarch 2013#

Images and Audio for each question for improvedusability and client engagement.#

Audio playback in options and icons.

Messages confirm answer or provide further counseling based on answer.#Scale-up strategies should involve building capacity of the entire organization to learn the technology and its components.

Proof of ConceptPilot Scale10 CHWs 40-500 CHWs ???

3#Technology costs made up only one third of total costs for scale-up annually. Training and staffing needs account for the remaining cost.

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Organizational training needs for CommCare adoption and scale-upMobileServerApplicationTroubleshootingMonitoringData AnalysisMaintenanceCHWSupervisorsTrainersOptionalTechnical Support ManagersData Staff#34Large ScaleCommCare Trainings

Technical & Supervisor TrainingTraining of Trainers

Training Users

Dimagi

Trainer

CHW

Supervisor/Tech Support#CHWBENEFICIARYCommCareHQ - ServerSUPERVISOR/DISTRICT/PROVINCEPROGRAM MANAGERS

Data is submitted to server from mobile to server via mobile internetSUPERVISORSupervisors follow-up and support CHW based on performanceSupervision & Monitoring of CHWsCommCare - MobileHOME VISIT

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Worker Monitoring Reports

Better CHW performance

Better health outcomes#Continuous Performance ImprovementSupport for Project Coordinators in managing workforceAnalyze all data submitted to server to improve worker performanceTargeted, actionable follow-up activities for supervisorsWeekly and monthly email reports

Design processes to support and improve CHWs service delivery based on evidence.

Accountability also extends to supervisors.

3#You can remove this I feel strongly about this (Mohini). At this point want to get partners to think about how would they use the performance data to improve service delivery of their workforce? This will take a while for them to figure out. Try it out for 3-4 months and then streamline use of these reports and exports. 38Supervision affects CHW performance

Limited time dedicated for supervisionHigh field staff turnover (challenge in learning tech)Limited/long delays in communication

Treatman, D., Bhavsar, M., Amland, N., Sharma, A., Swamy, K., Sheel, V. (2012). Performance Metrics Indicative of Supervision: A Study of Community Health Workers. IAMI Biennial Conference: New Delhi, India.#Continuous Performance ImprovementSupport for Project Coordinators in managing workforceAnalyze all data submitted to server to improve worker performanceTargeted, actionable follow-up activities for supervisorsWeekly and monthly email reports

Commcare Evidence#40Improved Access

85% More timely VisitsRandomized Controlled TrialB. DeRenzi, L. Findlater, G. Borriello, J. Jackson, J. Payne, B. Birnbaum, T. Parikh, N. Lesh, Improving Community Health Worker Performance Through Automated SMS, ICTD 2012, to appear#Ran study in Tanzaniathrough D-tree and PathfinderCHWs are expected to visit each client at least once per monthStudy was on 87 CHWs using CommCare. First studyHalf got nothing, half got SMS interventionSMS intervention was messages starting the day before visit due and continuing daily until form submitted On day 3 got message saying supervisor would be alerted (escalation)Dramatic results as shown in graph. 85% more timely visits. Second studyTested effect of escalation, by removing supervisor alerts from some of those getting it, and adding in SMS without supervisor alerts to others. Smaller samples but results indicate that supervisor alerts are key to the success of the program.

41Improved Quality20% Improvement to Protocol Adherence in a Randomized Controlled TrialIntrahealth Preliminary Result in India: ASHAs had increased their knowledge retention of at least 3-5 key danger signs from 48% at baseline to 70%Improvement in IMCI protocol adherenceB. DeRenzi, N. Lesh, T. Parikh, C. Sims, W. Maokla, M. Chemba, Y. Hamisi, and others, E-imci: improving pediatric health care in low-income countries, CHI 2008, pp. 753762.InvestigationCurrent practice adherencee-IMCI adherencep-valueVomiting66.7% (n=24)86% (n=28)-Chest indrawing75% (n=20)94% (n=18)-Blood in stool71% (n=7)100% (n=3)-Measles in the last 3 months56% (n=9)95% (n=21)< 0.05Tender ear0% (n=1)100% (n=5)-All61% (n=299)85% (n=359)< 0.01#See http://www.cs.washington.edu/homes/bderenzi/Papers/chi1104-bderenzi.pdfStudy done on PDAs, in southern TZ in 2007Clinician observed during interactions with patients. The observer has a checklist and ticks off which of the investigations required by IMCI were actually performed by clinician.In control, clinician did things as usualfrom memory or by referencing paper charts when they wantedIn intervention, clinician asked to use e-IMCI As results show, much better adherence using e-IMCIThis was preliminary and somewhat ad-hoc studyA follow on study by D-tree with much larger sample size and rigor has confirmed these results though. To be published soon.

42Improved ExperienceQualitative AssessmentPhones/CommCare add credibility to CHWsMultimedia helps engage clients and their familiesAudio helps CHWs recall key counseling messages Audio facilitates discussion on sensitive topics

Treatman, D., Lesh, N, Strengthening Community Health Systems with Localized Multimedia, M4D12 to appear.

Chittamuru, D. and Bhavsar, M. (2012). CommCare: Evaluation of a Mobile Application for Maternal Health in Rural India. IAMCR Durban: Communication Policy and Technology: Critical Perspectives on Digital Inclusion and Policy. Durban, South Africa.#Many focus groups and interviews done by Deepti Chittamuru, a PhD student from U.Penn, and Mohini Bhavsar from Dimagi. Results to be publishednot sure how much we should publish but do we do have some preliminary evidence.Also have lots of testimonials from ASHAs. 43Improved AccountabilityDetecting Surprising AnswersAnalyze distributions of answers by a CHW.ExampleQuestion: Did you give any referral in this household?Overall: 93% No, 7% YesCHW #3: 62% No, 38% YesDetects systematic errors Supports quality control

Detecting Fake Forms

(Work by Ben Birnbaum et. al. 2012)#44CHW Performance FeedbackIf ASHAs know their relative performance, does that encourage them to complete more of their visits?Background:There are a number of studies about relative vs absolute performance with variable outcomesWe want to understand how we can provide actionable feedback to the CHW

#45Active CC Investigations at a GlanceHypothesisExperiment ACCESS

CommCare increased number of family members who participate during a home visit/counseling session Comparing number of home visits and self-reported number of family members present during counseling sessions for ASHAs using CommCareQUALITY CommCare improves motivation of CHWs Studying motivation levels of CHWs in control site vs. CommCare intervention sites using job satisfaction survey CommCare improves knowledge of CHWs and reinforces training concepts Studying pre/post knowledge assessments CommCare increases client retention of information Test knowledge improvement amongst beneficiaries in CommCare intervention and control sitesEXPERIENCE CommCare allowed CHWs to discuss sensitive or taboo subjects. CommCare allowed CHWs to work around cultural and social barriers (use of multimedia) Studying patterns of multimedia usage in home visits where CommCare was usedACCOUNT-ABILITY Regular feedback to CHWs improves performance metrics Studying 2-3 performance indicators over 3 months for 60 CHWs in Madhya Pradesh, who received weekly performance feedback via Call Center* Two Large Evaluations Planned for 2012:+ Randomized controlled study in Bihar. Partnering with CARE and Mathematica Policy Research to assess the overall health impact of CommCare as a package intervention in the delivery of maternal and newborn health services in Bihar.+ Factorial randomized controlled study. Also partnering with the government of Kaushambi in Uttar Pradesh, Catholic Relief Services (CRS), Harvard Business School, and University of Washington to more deeply probe how CommCare influences CHW behavior and client outcomes. #46WANTED: Research CollaboratorsMULTIMEDIA

Dimagi is always looking for research partners to help carry out studies that will help lead to optimized mobile tools for Community Health Workers (CHWs) and improve health outcomes for their beneficiaries. We have lots of ideas/questions and are eager to hear yours!CHW PERFORMANCEHARDWAREDoes use of CommCare reduce worker turnover?Does use of CommCare/mobile tools increase credibility of CHWs? How can CommCare encourage a high rate of follow-up with clients?How is the user and/or beneficiary experience affected by hardware type?What else do CHWs try to do on their phones?Are smartphone versions of CommCare more intuitive for low-literate users?Does use of multimedia in CommCare increase retention of health info?Which types of multimedia are more effective than others?Can multimedia facilitate discussion about sensitive topics?

What we do: What we want to learn about:

#**Using multimedia for early childhood development videos/images/games to play with children to stimulate cognitive developmentcol stuff were looking into47WANTED: Research CollaboratorsPROJECT USABILITYHow can CommCare be optimized for low literate or illiterate users? What are the best practices for structuring/designing applications?How does CommCare help CHWs to plan and think about their work?What are major barriers to success for a CommCare project?Does use of CommCare in a project improve health outcomes?What elements are required for a successful mHealth project?DATADoes CommCare improve accuracy and/or timeliness of data?How can data be made actionable?What types of data visualization are most useful/broadly understood?

#Partnerships#49Design Your Own App

Field Test Your App w/ 10 free phones

Two Weeks Field Support(We train your project team & CHWs)

12 months Remote Support

Getting Started with Mobile Health!

#PREZI50

#Advantages of PartnershipsNGOs connected to local implementing NGOsHave the history of working in a region, relationships with key stakeholders:government /local officialscommunities/village councilshealth facilitiesCHWsLots of experience!Domain expertiseEmergent Collaboration52#

Sharing CommCare Apps on the Exchange#Exercise#54Application Builder

Create Your Own ApplicationOnline tools to build your own CommCare applicationCollect information including dates, multiple choice, images, video, bar code, and GPS.Create simple surveys or complex counseling forms

Download From the App StoreLeverage previously built apps to get started quicklyShare your own apps with the community

#55CommCare TutorialStep by step guide on how to create your first application!

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Step 1:Worksheet#Trying to get partners to narrow down questions they want to collect and counseling they want to provide. Assumption: Is all want to counsel, may not be true.

EXERCISE Fill out the worksheet OR Complete the CommCareHQ Tutorial and begin building yourfirst app? Id say do a tutorial?

57Thank you!Contact: mbhavsar@dimagi.com POC: poc-applications@dimagi.com Additional Videos:CommCare Overview Video: http://youtu.be/ZpfvISKxylECommCare Demo Video with multi-lingual support from India:http://youtu.be/30Ftk6STM3URecorded Webex of CommCare Presentation given to NetHope: http://bit.ly/tiLaYy

Additional Resources: http://groups.google.com/group/ict4chwhttp://www.commcarehq.orghttp://www.dimagi.com

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Dimagi Global Head-office585 Massachusetts AveCambridge, MA 02139 USAT: +1.617.649.2214F: +1.617.274.8393

For more InformationE: information@dimagi.comW: www.dimagi.comW: www.commcarehq.orgW: www.dimagi.com/category/blog/

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